PA SPREAD, PA Area Health Education Center (AHEC), and Pittsburgh Regional Health Initiative (PRHI) propose to move 8 small- to mid-size networks (2 per year of this 4-year grant) towards a population-based health care system. Through population management-based quality improvement, participating networks will work to improve the quality, effectiveness, efficiency and safety of the care they deliver. PA SPREAD aims to: (1) Leverage existing relationships with primary care practices and health systems to spread the quality improvement and population management foundation across entire primary care networks to prepare networks to function as accountable care organizations capable of coordinating and improving the care and health of their communities. (2) Build capacity within primary care networks for ongoing practice facilitation, IT support, change management, and quality improvement. (3) Support widespread adoption of evidence-based clinical guidelines and care delivery best practices by developing regional and statewide learning communities supported by local practice facilitation. Primary network-based outcomes include the improvement of performance rates on nationally-used clinical quality measures for heart disease, diabetes, hypertension and asthma to the most recently available 90th percentile HEDIS benchmark within 4 years in participating practices PA SPREAD, AHEC, and PRHI will work to develop self-organizing capacity for quality improvement within participating practices and networks through four main interventions. Learning Communities will blend PA SPREAD/AHEC and PRHI models to allow for more frequent meetings to accelerate improvement and provide additional opportunities to assist networks to develop their self-organizing capacity. Additionally, PA SPREAD will work with the PA Department of Health to build upon its existing best practices webinars to develop a statewide learning community involving any practice or network working on population management-based quality improvement. Participating networks will be provided a population management roadmap for improvement that will focus on (1) planned care and risk assessment at every visit using proactive team-based care, (2) patient self-management support, education, and activation, and (3) care coordination. In addition to providing direct practice facilitation support to practices ad networks, the PA SPREAD partnership will work simultaneously to build facilitation capacity within each network. Within a year, PA SPREAD/AHEC/ PRHI facilitators will work to transition practice facilitation to network-based practice facilitators. Monthly performance reporting and benchmarking will be at the practice population level to enable assessment of each practice's success in testing and implementing changes in the context of its unique environment, organization, culture, and characteristics.